16 million have lost Medicaid coverage since redeterminations began

Photo: Photo by d3sign/Getty Images

Ten months after states began the redetermination process, an estimated 16 million beneficiaries have lost Medicaid coverage, according to KFF analysis.

In December 2022, the Urban Institute predicted that upwards of 18 million people could lose Medicaid coverage when the COVID-19 public health emergency expired. This prediction appears to be on target with KFF research of enrollment numbers.

States have now reported renewal outcomes for half of all enrollees. Thirty four percent (32.1 million) have had their coverage renewed and 17% (16.2 million) have been disenrolled, according to KFF's latest analysis of state-level data.

There are reasons to expect disenrollment rates to moderate in the second half of the unwinding as states reduce procedural disenrollments and work through "likely ineligible" populations, the report said.

Data on the number of people re-enrolling in Medicaid after being dropped, transitioning to employer coverage or becoming uninsured are currently limited, KFF said.

The continuous enrollment provision during the COVID-19 pandemic ensured Medicaid beneficiaries kept their health coverage, but when the federal government announced in January the upcoming end of the public health emergency on May 11, states were allowed to begin their Medicaid renewal processes on April 1.

Since the start of the unwinding, Medicaid enrollment has declined by about 10% nationally, with decreases in every state, ranging from 32% in Idaho to 1% in Maine, KFF said. Two states -- South Dakota and North Carolina -- expanded Medicaid in 2023, which is expected to help limit enrollment declines in those states.

To date, 41 states, including the District of Columbia, have adopted Medicaid expansion and 10 states have not adopted the expansion, according to a KFF report in December 2023. Originally a mandate of the ACA, Medicaid expansion was left to the determination of individual states following a ruling by the Supreme Court.

In the 10 states that have not adopted Medicaid expansion, nearly 1.5 million uninsured individuals fall into the "coverage gap," and are not eligible for Medicaid or ACA Marketplace subsidies, KFF said.

WHY THIS MATTERS

In May, the American Hospital Association, citing a Kaufman Hall report, said Medicaid disenrollments were a looming concern for hospitals already operating close to the margin. Without coverage, patients were less likely to seek care until severe sickness sent them to the emergency room. This would affect hospitals' charity care and increase bad debt claims.

The proportion of self-pay patients began increasing for emergency department, hospital and primary care visits following the start of the redetermination process, according to a November study from Epic Research.

Concerned over predictions of millions losing coverage - most without knowledge that the unwinding was happening - the federal government, through the Centers for Medicare and Medicaid Services, opened a special Affordable Care Act enrollment period for beneficiaries no longer insured through Medicaid or the Children's Health Insurance Program (CHIP). The temporary Exceptional Circumstances Special Enrollment Period opened on March 31, 2023 and extends through July 31 of this year.

While the final number of former Medicaid beneficiaries who are signing up during the special enrollment period has yet to be determined, the latest regular ACA open enrollment period that just ended on January 16 shows what CMS calls an "historic enrollment" of 21.3 million people. Total plan selections include more than five million people -- about a fourth -- who are new to the ACA marketplaces and 16 million people who renewed their coverage. 

KFF said that while national data show record enrollment in ACA marketplace coverage, a relatively small share of this growth appears to come from people who have transitioned from Medicaid to the marketplace.

THE LARGER TREND 

On April 1, for the first time since the pandemic began, states began reviewing individuals enrolled in Medicaid to determine whether they still qualified for coverage.

During the public health emergency starting in March 2020, anyone enrolled in Medicaid retained coverage due to a continuous enrollment provision that was backed by federal funds. This January, the Biden administration gave a heads up that the PHE would end on May 11. States, which would no longer receive continuous enrollment funding for Medicaid, were told they'd be able to resume the regular renewal processes on April 1.

Email the writer: SMorse@himss.org